Education, justification & optimization get to heart of safe imaging

The American Heart Association (AHA) is promoting three pillars to maximize radiation safety in patients who undergo cardiovascular imaging: education, justification and optimization. Several societies endorsed the recommendations, which were published online Sept. 29 in Circulation.

Cardiovascular imaging contributes to almost 40 percent of medical radiation exposure to patients in the U.S., according to the authors of the scientific statement. That finding prompted the AHA to explore exposure patterns and risks of ionizing radiation and develop strategies for safe use. Their recommendations fall under the three categories, with education and justification applying to referring physicians and optimization to clinicians who perform the procedures.

The authors recommend that if providers request ionizing cardiac imaging tests for their patients, they first should know basic concepts about exposure, absorbed dose, effective dose and dose estimates. They should weigh the merit of the imaging modality, keeping in mind that a method that does not expose the patient to radiation may be an option. Other considerations include diagnostic accuracy, potential risks, availability, cost and convenience.

Interventional cardiologists, electrophysiologists and physicians who conduct imaging tests should have demonstrable knowledge in dose optimization techniques as well as dose minimization for staff and operators.

In addition, nonemergent imaging using CT, radiopharmaceuticals or fluoroscopy should be a shared decision based on evidence and patient preference with an informed patient, they wrote.  

Under justification, they stressed the need of appropriate testing and encouraged physicians to use appropriate use criteria (AUC). “Of course, there are inherent limitations to the use of AUC,” the authors acknowledged. “Because of practical limits in length and detail, they cannot address every clinical scenario.”  

Optimization requires that the test be appropriate, clinically needed, and performed with a minimum of radiation to achieve adequate diagnostic accuracy. In cases where radiation exposure to the patient in a fluoroscopy procedure exceeds the institutional trigger, physicians should arrange for clinical follow-up for early detection and management of any skin injury, they wrote.

They recommended that cardiac imaging facilities record radiation-related data and audit and store exposure reports to benchmark and track quality. They called for trials, comparative-effectiveness studies and registries that have a cardiac imaging component to also collect and report radiation exposure data.  

As technology evolves, they encouraged physicians to look for opportunities to lower radiation exposure and ensure safe practices. “The implementation of these strategies in practice is necessary to achieve high-quality, patient-centered imaging and will require a shared effort and investment by stakeholders, including physicians, patients, national scientific and educational organizations, politicians, and industry,” they concluded.

The statement was co-chaired by Reza Fazel, MD, MSc, of Beth Israel Deaconess Medical Center in Boston, and Thomas G. Gerber, MD, PhD, of the Mayo Clinic in Rochester, Minn. The statement was endorsed by the American College of Cardiology, The American Society of Nuclear Cardiology, the North American Society of Cardiovascular Imaging, the Society of Cardiovascular Computed Tomography and the Society for Coronary Angiography and Interventions.

Candace Stuart, Contributor

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